CHC Study Guide - Factors✔✔ 1. upper-level employee participa...

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CHC Study Guide 1.Federal Sentencing Guidelines - Culpability Score Aggravating Factors✔✔ 1. upper-level employee participates, condones, or ignores offense 2.repeat offense 3.hinder investigation 4.awareness and tolerance of violation is pervasive

• Federal Sentencing Guidelines - Culpability Score Mitigating

Factors✔✔ 1. effective compliance program 2.reported promptly 3.cooperation with investigation 4.accept responsibility

• Federal Sentencing Guidelines - Seven Elements of an Effective

Compli- ance Program✔✔ 1. written standards of conduct 2.Chief Compliance Officer 3.effective education and training 4.audits and evaluations to monitor compliance 5.reporting processes and procedures for complaints 6.appropriate disciplinary mechanisms 7.investigation and remediation of systematic problems 4.The only thing worse than not having a policy is......having a policy and 1 / 4

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not following it.

5.Medicare reimbursement - hospital inpatient codes✔✔ International Classifica- tion of Diseases (ICD) 6.Medicare reimbursement - physician codes✔✔ Current Procedural Technology (CPT) 7.Questions to guide the scope of an internal investigation.✔✔ 1. What is the origin of the issue?

2.When did the issue originate?

3.How far back should the investigation go?

4.Can extrapolation of a statistical sample be used?

8.It is in the best interest of the organization to have the board .✔✔ - ...take an active rather than a passive role in compliance.

9.Six tips for saving on future costs of compliance.✔✔ 1. embed quality into existing processes 2.centralize common processes and controls 3.improve human resources infrastructures 4.improve information systems processes 2 / 4

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5.emphasize training 6.monitor marketing and compensation

• Baseline Audit Process✔✔ 1. outline the current operational

standards 2.identify real and potential weaknesses 3.offer recommendations

• Compliance Program - Measures of Effectiveness✔✔ 1. staff

knowledge 2.all 7 elements included 3.comparing issues year to year 4.tracking and trending complaints 5.tracking corrective actions 6.reviewing current audits 7.educational session pre and post tests 8.tracking bill denials 9.organizational survey results 10.audit results 11.compliance topics on department/organization agendas 12.Modifier✔✔ a two digit alpha/numeric code used in conjunction with CPT or HCPCS codes that may increase or decrease reimbursement gives new meaning to the code 13.International Classification of Diseases (ICD)✔✔ a statistical 3 / 4

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classification system that arranges diseases and injuries into groups according to established criteria (signs and symptoms) 14.Current Procedural Terminology (CPT)✔✔ American Medical Association pub- lishes and maintains this coding system 15.Organized Health Care Arrangements (OHCA)✔✔ HIPAA arrangement be- tween clinically integrated setting (ex✔✔ hospitals and medical staff) 16.Diagnosis Related Group (DRG)✔✔ an inpatient classification system based on✔✔ principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status 17.Healthcare Common Procedure Coding System (HCPCS)✔✔ for medication, maintained by CMS CMS contracts with American Medical Association to use CPT coding for the Medicare program using this expanded version

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